Short Term Outcome of Laparoscopic Anterior Resection for Rectal Carcinoma.

Colorectal cancer is the second most common malignancy in the western countries and the rectum is the most frequent site involved. Carcinoma in the rectosigmoid junction, upper and middle 3rd of the rectum is now successfully managed by laparoscopic AR and postoperative morbidities are less and recovery is uneventful. The advantages of laparoscopic surgery are smaller incisions, shorter recovery time and less wound related complications. However the narrow confines and angulations of the bony pelvis and the standard practice of autonomic nerve sparing total mesorectum excision has made laparoscopic surgery in the setting of rectal cancer more challenging. This study was carried out in the Colorectal surgery Department, Bangabandhu Sheikh Mujib Medical University, Dhaka from April 2018 to March 2019. Forty (40) cases were selected according to inclusion criteria. Twenty (20) patients treated by conventional open AR were known as control group and rest 20 patients treated by laparoscopic AR were known as Experimental group. Patient's particulars, pre operative diagnosis, operative findings were recorded in a pre designed data sheet and postoperative follow up and early outcomes of the patients of both groups were recorded by the same manner to find out general and local complications till discharge. Postoperatively all the patients were referred to oncology department and advised to come for follow up after 2 weeks (1st follow up). Mean age of experimental group was 43.40 and standard deviation was 13.59. In both age groups, age was not a contraindication. In the both groups number of male is slightly higher than female. Laparoscopic anterior resection can be performed safely and effectively. During post-operative follow up no significant morbidities and complications were observed in post-operative period in both groups of population. Degree of pain along with use of analgesia is also less after laparoscopic AR. Ambulation, stoma function, feeding liquid and feeding solid all occurred earlier for experimental group. Mean length of hospital stay for experimental group was found to be shorter than that of control group. Early hospital discharge was possible after laparoscopic AR. Oncological parameters were equivalent to those of open procedures. Laparoscopic AR is acceptable for rectal carcinoma.

Postoperative Outcome of Fistulotomy with Marsupialization in the Surgical Management of Simple Anal Fistula Comparison between Fistulotomy-layopen Procedures.

Assess the wound healing time and early post-operative outcome of fistulotomy with marsupialization, as a surgical treatment of simple fistula-in-ano. This interventional study was performed at the Department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University, Bangladesh from July 2017 to June 2018. Total 30 cases of simple anal fistula were selected according to inclusion criteria. Patients were non-randomly divided in two groups. Fifteen (15) cases were undergone a fistulotomy-lay open (control group) and another 15 cases undergone a fistulotomy with marsupialization (experimental group). The result was tested by t-test, chi-square test. Statistical significance was set at p<0.05. The mean age of the study population was 42.07±13.69 years in fistulotomy-lay open group and 46.00±12.99 years in fistulotomy with marsupialization group. In both group, number of male was higher. Perianal discharge and induration or swelling at perianal skin was most common findings. Mean healing time was earlier in fistulotomy with marsupialization group (16.60±11.15 days) than lay open group (27.07±14.28 days) due to marsupialization technique, the matter of fact that the deep, unepithelized wound has become smaller. No significant difference of postoperative pain, bleeding, wound infection and fecal incontinence in both group. The study shows marsupialization of the wound after fistulotomy for simple fistula in ano results in significantly faster healing in comparison with lay open-fistulotomy, less bleeding without increasing postoperative pain and the infections.

Clinical Outcome of 0.2% Glyceryl Trinitrate Topical Ointment Compared to Lateral Internal Sphincterotomy in the Treatment of Patient with Chronic Anal Fissure: A Randomized Control Trial.

The objective of study was to evaluate the clinical outcome of topical 0.2% Glyceryl trinitrate topical (GTN) ointment in the treatment of chronic anal fissure. This randomized control trial was carried out in the Colorectal Surgery Unit, Department of Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from May 2015 to April 2016. Total 94 patients were included in this trial, where 47(50.0%) patients were treated by 0.2% GTN ointment as Trial group 12 hourly for 8 weeks and 47(50.0%) patients by lateral internal sphincterotomy (LIS) as Control group in this study. Patients were randomized in two groups by lottery following purposive sampling. Post-procedural outcome variables with 6 months follow up were evaluated. Majority of the patients were found in between 20 to 40 years of age in both groups. The mean age was 34.6±10.4 years and 33.2±8.6 years in GTN and LIS respectively. Overall male female ratio was 0.88:1. All (100.0%) patients presented with pain in anus and 86.15% patients presented with per rectal bleeding. Pain relief in GTN arm versus LIS arm in 2nd and 6th week was 55.31% vs. 76.6%, 74.5% vs. 87.23% with no significant difference between two groups. But at 6 month it was 57.44% vs. 93.6% respectively. The fall in pain relief at 6th month in GTN arm was due to recurrence of fissure. At the end of 2nd, 6th week and 6month, cessation of bleeding improved gradually in both groups after treatment but the improvement was significantly better in LIS group than in GTN group indicating sphincterotomy stops bleeding better. Healing after 2nd week in both groups was minimum but equal 2(4.26%) patients. After 6 weeks LIS group had significant better healing than GTN 40(85.1%) versus 26(55.3%) with p value <0.001. In 6 month time GTN group had increased healing but LIS group had significant better healing than GTN group 42(89.36) vs. 32(68.08) with p value 0.004. Transient flatus and liquid incontinence were 8.51% and 6.4% respectively in LIS group with 0.0% in GTN group. Headache and recurrence were significantly higher in GTN group 61.7% and 34.04% with p<0.001. Lateral internal anal sphincterotomy is superior to the topical application of 0.2% nitroglycerin ointment in the treatment of chronic anal fissure with the advantages of good symptomatic relief, high rate of healing and a very low rate of transient continence disturbances.

Evaluation of Short Term Outcome of Stapled Transanal Rectal Resection (STARR) for ODS (Obstructed Defecation Syndrome) by Comparing Pre and Post-operative ODS Score.

Obstructed defecation syndrome (ODS) is a common anorectal problem and it can be corrected by various surgical approaches but most of these have high recurrence and complication rates. Antonio Longo introduced Stapled transanal rectal resection (STARR) in 2003 as a minimally invasive transanal operation for correction ODS associated with rectocele and or rectal intussusception. This study was designed to assess the short term outcome of Stapled Transanal Rectal Resection (STARR) as a surgical treatment of Obstructed Defecation Syndrome (ODS). This is a quasi experimental study which was carried out in the department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from May 2016 to June 2017. Seventeen (17) patients were included in the study. Patients with obstructed defecation syndrome and rectocele and or rectal intussusception admitted in the department of Colorectal Surgery were enrolled in the study as per inclusion and exclusion criteria. History, clinical examination, Proctoscopy, Colonoscopy and MR Defecography was done for evaluation of the patients. During evaluation preoperative Longo's ODS score of every patient also determined and compared with postoperative ODS score. The patient was followed up regularly at one, three and six months after each operation. The ODS score in 82.35% patients improved significantly. The postoperative score was high (13-15) only in 02(11.8%) patients probably due to presence of physiological factors. Post-operative defecatory urgency was developed in only 02(11.76%) patients. Major postoperative complication like hemorrhage or rectovaginal fistula did not develop in any patient. STARR is an effective, less invasive and simple procedure for the treatment of ODS with rectocele and/or rectal intussusception without major morbidity but other physiological causes of ODS should exclude preoperatively because its presence makes the surgical intervention fruitless.

Milestones of Development in Infancy: A Prospective Study in a Tertiary Level Hospital of Bangladesh.

The timing of milestone is influenced by many factors. Sex and socioeconomic status has significant effect to some psycomotor milestones. The study was conducted to determine the pattern of milestones of development of infants in our country and to compare it in different sex and socioeconomic condition. It was a hospital based prospective study done in Sir Sallimullah Medical College and Mitford Hospital, Dhaka, Bangladesh from October 2014 to November 2015. Healthy term newborn infants with average birth weight were included in this study and milestones of this birth cohort were assessed monthly from birth to 12 months of age by using a set of 60 milestones. Total number of 217 babies was enrolled but during follow up 0.9% developed meningitis, 43.7% was lost to follow up and 55.2% of the cohort was followed up to 12 months of age. Among 120 babies 51.7% were male, 48.3% were female babies and 51.7% belong to lower, 32.5% middle and 15.8% upper socioeconomic group. There was no significant difference between male and female infants achieving most of the milestones of development except in language development in which female infants were little bit higher than male infants.

Giant Villous Adenoma: A Rare Case of Colorectal Adenoma that Mimic Colorectal Cancer.

Colorectal cancer being the 4th most common cause of cancer death in which most arise from a preexisting adenomatous polyp. Among the various adenomas Giant villous adenoma (GVA) is less common. We came across a 65 years female with intermittent per rectal mucus discharge for last 10 years and intermittent fresh, painless, scanty per rectal bleeding along with weakness and fatigue for last 5 years. No members of her family had been suffering from colorectal malignancy. DRE revealed irregular gritty feelings of rectal mucosa starting 2cm from anal verge and the examining fingertip was blood tinged mixed with mucus. On proctoscopic examination the accessible rectum was studded with thousands of polyps with granular appearance, with variable sizes and there was mucus mixed blood within the rectum. Colonoscopy reveals- polypoid lesion starting 2cm from anal verge and extends up to 2cm with granular and velvety appearance. Biopsy was done 2 times for suspicious lesion and histopathology reveals tubulovillous adenoma with dysplasia. However as clinical suspicion of an adenocarcinoma was strong but histopathological report of colonoscopic biopsy was contradictory, intersphincteric ultra-low anterior resection with coloanal anastomosis with covering ileostomy was done. Resected specimen was sent for histopathological study and it reveals- villous adenoma with low grade dysplasia. Two months later reversal of ileostomy was done and now the patient is under regular follow up and now she is asymptomatic.

Legg-Calve-Perthes Disease: Correlation between Computed Radiography and Magnetic Resonance Imaging.

The purpose of this study is to diagnose Legg-Calve-Perthes disease by computed radiography and Magnetic resonance imaging and accurate staging and correlating the findings of these two modalities. Thirty five (35) patients complaining pain in groins and painful walking, after thorough physical examinations were sent to Department of Radiology & Imaging, Mymensingh Medical College Hospital, Mymensingh, Bangladesh for computed radiography and Magnetic Resonance Imaging examination. This cross sectional study was conducted in the Department of Radiology, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from July 2016 to June 2018. Legg-Calve-Perthes disease among the selected 35 cases were started at the age of 5(2.9%) and age range of the patients were 5-13 years; mean age was (9.63±1.82) years and most of them belonged to 8-10 years of age (51.4%). Patients with Legg-Calve-Perthes disease had been suffering from pain in right and left groins forvarious durations. Maximum duration was 1-2 years (~88.57%). Maximum proportion of diagnosed patients was delivered by normal delivery (60%) and maximum proportion of patients was premature (65.7%). Most of the patients were low birth weight baby (65.7%). Here chi-square test was done and found no significant relationship between delivery mode and birth weight in case of Legg-Calve-Perthesdisease (x²=1.712) (P=0.191). The result of the X-ray and MRI findings by cross table of chi square test found fair inter relationship between two diagnostic instruments. Result found fine difference in staging of the disease between X-ray and MRI findings. It can be said that MRI definitely a better tool for early diagnosis of Legg-Calve-Perthes disease and its staging but X-ray modality can be used. A primary tool for diagnosis and staging of the disease can be done where the MRI facility is not available or cost expensive for patient.

The Role of Histological Assessment of Distal Doughnut in Low Anterior Resection for Low Rectal Cancer.

Anterior resection (AR), especially low anterior resection (LAR), for low rectal cancer and colorectal anastomosis is a technical challenge to surgeons. But by using circular stapling devices now it is possible make more LARs technically feasible. A stapled end-to-end colorectal anastomosis is increasingly adopted following a low anterior resection for low rectal cancer. This descriptive cross-sectional study was carried out in the department of Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from December 2015 to December 2016. The ensuing doughnuts created from the stapling device are routinely sent for histological analysis. However, its efficacy remains debatable. This study aims to determine the role of sending distal doughnut for histological examination following a stapled end-to-end colorectal anastomosis done in low anterior resection for low rectal cancers.

Correlation between Clinical Diagnosis and Colonoscopic Findings of Patients Presented with Lower Gastrointestinal Bleeding.

Lower gastrointestinal bleeding is a frequently encountered problem in general medical practice. This bleeding comes from a site distal to ligament of Treitz. But it may also come from upper gastrointestinal tract when it is massive and pass through the stool. This study was intended to explore the causes of lower gastrointestinal bleeding and correlating them with their colonoscopic findings. This study was cross-sectional prospective. Sample was taken purposively. Out of 200 patients which were selected for the study, 122(61%) were male and 78(39%) were female with a male to female ratio of 5:3. The ages of the patients were ranging from 5 to 80 years with the mean age of 41.9±15.0 years; maximum 38(19%) patients were in 51 to 60 years. All patients were presented with per rectal bleeding & underwent colonoscopy & maximum 57(28.5%) patients were diagnosed as hemorrhoids, followed by colorectal cancer in 55(27.5%) cases. In 10(5%) cases of haemorrhoids 2nd pathology was found associated with it. In 32(16%) cases colonoscopic findings were normal. It was concluded that the most common cause of lower gastrointestinal bleeding was hemorrhoids followed by colorectal cancer. But several cases of colon cancer were misdiagnosed clinically as colitis. So clinical diagnosis should be correlated & confirmed by colonoscopy and biopsy.